patient registration form · 2019-11-07 · male . race: african american/black american...
TRANSCRIPT
Last Name: _____________________ First Name: ____________________ Middle Name: ____________________
Date of Birth: _________________________ Gender: Male
Race: African American/Black American Indian/Alaskan Native Asian
Female Other
Caucasian/White Native Hawaiian/Pacific Islander Other _____________________ Declined
Ethnicity: Hispanic or Latino Non-Hispanic or Latino Unknown Declined
Primary Language: ____________________ Marital Status: Single Married Widowed Separated
Street Address: ____________________________________________________________________________________
City: _______________ State: ________ ZIP: _________ County: ____________
Home Phone: ___________________ Work Phone: _____________________ Cell Phone: ____________________
Email: _____________________________________
Emergency Contact: _______________________________________________________________________________
Relationship: __________________________________________ Phone: ________________________________
Referring Physician: ____________________________________ Phone: ________________________________
Address: ______________________________________________ Fax #: _________________________________
Primary Care Physician: ________________________________ Phone: ________________________________
Address: ______________________________________________ Fax #: _________________________________
Pharmacy Name: _______________________________________ Phone #: _______________________________
Address: ______________________________________________ Fax #: _________________________________
Patient Registration Form
Preferred Communication:____________________________
Is patient at a Skilled Nursing Facility? NO YES _________________________________Name of Skilled Nursing Facility
Page 1 revised 11-07-19
INSURANCE INFORMATION
Primary Insurance Company: _______________________________________________________________________
Policy #: __________________________________________________ Group #: _____________________________
Subscriber / Insured’s Name: ________________________________ Date of Birth:__________________________
Subscribers SSN #: __________________________________ Relationship to Insured: _______________________
Does your insurance require a referral? Yes No
Secondary Insurance Company: ______________________________________________________________________
Policy #: __________________________________________________ Group #: _____________________________
Subscriber / Insured’s Name: ________________________________ Date of Birth:__________________________
Subscribers SSN #: __________________________________ Relationship to Insured: _______________________
Does your insurance require a referral? Yes No
WORKERS COMPENSATION INFORMATION (If applicable)
Workers’ Compensation Insurance: __________________________________________________________________
Claim #: _________________________________________ Phone #: _______________________________________
The above information is true to the best of my knowledge. I authorize my insurance benefits be paid directly to
the physician. I also authorize New Jersey Urology or my insurance company to release any information
required to process my claims. I understand that I am financially responsible for any amount not covered by
insurance. I have been informed that copays, deductibles, and any outstanding balances are expected at the time
of visit.
__________________ ___________________________________
Patient Signature Date
___________________________________
Authorized Representative Signature
__________________
Date
Adjuster's Name: ________________________________________
NO FAULT INFORMATION (If applicable)
Claim #: _________________________________________ Phone #: _______________________________________
No Fault Insurance: ________________________________________
Employer's Name ___________________________ Address: __________________________ ___________________
Page 2 revised 11-07-19
Last Name: _____________________ First Name: ____________________ Middle Name: ____________________